COPAIA 7. Alianza estratégica para la creación de capacidades en análisis de riesgos para la inocuidad de los alimentos en las Américas

El principal objetivo de este trabajo es brindar las bases para un esfuerzo coordinado con el fin de crear capacidad de análisis de riesgos para la inocuidad de los alimentos en la región de América Latina y el Caribe (ALC) reuniendo a organizaciones internacionales (Organización Panamericana de la Salud-OPS, Organización de las Naciones Unidas para la Alimentación y la Agricultura -FAO e Instituto Interamericano de Cooperación para la Agricultura-IICA) y universidades (Universidad de Nebraska-Lincoln, Universidad de Maryland, Universidad de Minnesota y Universidad Tecnológica de Texas) mediante la Alianza Estratégica para la Creación de Capacidades en Análisis de Riesgos para la Inocuidad de los Alimentos (AECAR). Esperamos que este trabajo, creado por la alianza, logre: a) generar confianza y fortalecer la comunicación entre todas las organizaciones que trabajan en la región; b) proporcionar las bases para enfoques coordinados, consistentes y efectivos para crear capacidad y desarrollar programas de estudio; y c) facilitar la implementación del marco para análisis de riesgos en la región. Este trabajo presenta los recursos actuales de los autores, considera algunos ejemplos exitosos de implementación de análisis de riesgos en la región (de los sectores académicos y gubernamentales), los desafíos experimentados al implementar el análisis de riesgos, y una hoja de ruta para la creación de capacidad propuesta por esta alianza para ampliar la adopción de análisis de riesgos en la región.

The main goal of this paper is to provide the foundation for a coordinated effort for food safety risk analysis capacity building in the Latin American and Caribbean (LAC) region by bringing together international organizations (Panamerican Health Organization-PAHO, Food and Agriculture Organization of the United Nations-FAO and the Interamerican Institute for Cooperation in Agriculture-IICA) and universities (University of Nebraska-Lincoln, University of Maryland, University of Minnesota and Texas Tech University) through the Strategic Alliance in Risk Analysis Capacity Building (SARAC). We expect that this paper, authored by the alliance, will: a) build trust and strengthen communication among all the organizations that work in the region; b) provide the foundation for coordinated, consistent, and effective approaches to capacity building and curriculum development; and c) facilitate the implementation of the risk analysis framework within the region. This paper provides the current resources by the authors, discusses some successful examples of risk analysis implementation in the region (from academia and government sectors), the challenges experienced on implementing risk analysis and a capacity building roadmap proposed by this alliance to enhance the adoption of risk analysis in the region.

Total homocysteine levels in healthy children from the Monterrey metropolitan area, Mexico.

Currently, there are indications for determining hyperhomocysteinemia in adulthood as risk factors for cardiovascular diseases, psychiatric disorders, pregnancy complications, birth defects, cognitive impairment in the elderly, in addition to cancer. If hyperhomocysteinemia is determined from childhood, it may be modulated with the provision of an opportunity for public health intervention. The objective of this descriptive study was to determine total homocysteine (tHcy) levels in healthy children from the Monterrey metropolitan area in Mexico. In a peripheral-blood sample collected from 56 healthy children aged 2-10 years, we determined tHcy concentration by high performance liquid chromatography (HPLC) with fluorescence detection. The geometric mean +/- SD was 9.78 +/- 1.73 micromol/l. tHcys of the children studied were homogeneous by age cohort and gender. Nutritional state was classified by body mass index (BMI). Sixty five percent of children who participated in the study had normal BMI, and 96% of the children belong to the low socioeconomic status. In conclusion, to our knowledge this is the first-ever information on homocysteine (Hcy) prevalence in a population of healthy Mexican children. tHcy concentration was higher than that reported in other populations studies. This preliminary study could constitute the baseline for future public health studies.

How people respond to illness in Mexico: self-care or medical care?

OBJECTIVE: To analyse illness factors associated to the form of attention (self-care or medical care) used to resolve health problems in Mexico. METHODS: A total of 5640 individuals who reported sickness within the 2 weeks before the application of the 1994 National Health Survey were analysed. A descriptive analysis was conducted to study demographic and socioeconomic characteristics, access to medical services, perception of seriousness of the illness, treatment received, and reasons why medical care was not sought. Factors associated with the form of attention (self-care or medical care) were identified through logistic regression. RESULTS: Sixty-one percent of the sample was self-attended. Of those who perceived their illness as serious, 52% did not use medical services because they considered them too expensive or did not have the money to pay. In the multivariate analysis, a greater frequency of self-care was observed among males over 5 years old who lacked access to Social Security medical services, or system of private insurance, suffered a mild illness, and lived in poor, rural areas. DISCUSSION: In Mexico, self-care represents the most important response to illness. Socioeconomic conditions, regardless of the perception of seriousness of the symptoms, determine the higher frequency of self-care mainly among those people living in poverty.

Natural fertility in northeastern Mexico: genetic structure by year of birth and birthplace.

BACKGROUND: The aims of this population genetics study were 1) to ascertain whether 417 Mexican women with natural fertility (45 years of age, married, not using any family planning methods, residing in the state of Nuevo León) were genetically homogeneous, and 2) to compare the genetic structure of this selected population with the previously reported data of random populations of northeastern Mexico. METHODS: A sample of 417 women was interviewed and selected in seven medical units of the Mexican Social Security Institute. They were grouped by their year of birth (1896-1925 and 1926-1955) and birthplace [persons whose four grandparents were born in the northeastern states (NE) and outside the northeastern states (Not-NE) of Mexico]. Eight genetic marker systems were analyzed. RESULTS: Gene diversity analysis suggests that more than 99.1% of the total gene diversity can be attributed to variation between individuals within the population. Genetic admixture analysis suggests that this selected population, stratified by year of birth and birthplace, have received a predominantly Spanish contribution followed by a lesser Mexican Indian contribution. CONCLUSIONS: The genetic structure of this selected population was homogeneous and similar to the random populations of northeastern Mexico. This finding corroborates the utility of this selected population for genetic and epidemiological studies.

Estimation of nonpaternity in the Mexican population of Nuevo Leon: a validation study with blood group markers.

A method for estimating the general rate of nonpaternity in a population was validated using phenotype data on seven blood groups (A1A2BO, MNSs, Rh, Duffy, Lutheran, Kidd, and P) on 396 mother, child, and legal father trios from Nuevo León, Mexico. In all, 32 legal fathers were excluded as the possible father based on genetic exclusions at one or more loci (combined average exclusion probability of 0.694 for specific mother-child phenotype pairs). The maximum likelihood estimate of the general nonpaternity rate in the population was 0.118 +/- 0.020. The nonpaternity rates in Nuevo León were also seen to be inversely related with the socioeconomic status of the families, i.e., the highest in the low and the lowest in the high socioeconomic class. We further argue that with the moderately low (69.4%) power of exclusion for these seven blood group systems, the traditional critical values of paternity index (PI > or = 19) were not good indicators of true paternity, since a considerable fraction (307/364) of nonexcluded legal fathers had a paternity index below 19 based on the seven markers. Implications of these results in the context of genetic-epidemiological studies as well as for detection of true fathers for child-support adjudications are discussed, implying the need to employ a battery of genetic markers (possibly DNA-based tests) that yield a higher power of exclusion. We conclude that even though DNA markers are more informative, the probabilistic approach developed here would still be needed to estimate the true rate of nonpaternity in a population or to evaluate the precision of detecting true fathers.

Infant and child growth and fatness and fat distribution in Guatemalan adults.

To examine whether poor growth in utero or young childhood is associated with adult abdominal fatness in a developing country context, the authors analyzed prospectively collected data on 372 female and 161 male Guatemalans measured as children between 1969 and 1977 and remeasured as adults in 1988-1989 (men and women) and 1991-1994 (women only). Childhood stunting (height-for-age z score) was associated with a lower body mass index and percent body fat in men, while no associations were found in women. In both sexes, however, severely stunted children had significantly greater adult abdominal fatness (waist:hip ratio), once overall fatness and confounders were controlled. The adult waist:hip ratio (x100) was increased by 0.65 (95% confidence interval 0.10 to 1.20) in men and 0.29 (95% confidence interval -0.03 to 0.61) in women for each height-for-age z score less at age three. Migration to urban centers was significantly associated with an even greater waist:hip ratio in severely stunted females (p = 0.03). In a subsample of 137 women, short and thin newborns had significantly greater adult abdominal fatness compared with long and thin or short and fat newborns or children who became stunted postnatally. The adult waist:hip ratio (x100) was increased by 1.58 (95% confidence interval 0.35 to 2.81) for each kilogram less birth weight. The authors conclude that, in countries where maternal and child malnutrition exists alongside rapid economic development and urban migration, abdominal obesity and related chronic diseases are likely to increase.

PIP: Being overweight, especially in the abdominal region, is a risk factor for cardiovascular disease, the onset of diabetes in adults, stroke, and mortality. Malnutrition in utero or early childhood may lead to fatness later in life. The authors tested the hypothesis that poor linear growth during childhood predicts fatness and the high-risk fat patterning of young Guatemalan adults. Findings are based upon the analysis of prospectively collected data on 161 male and 372 female Guatemalans measured as children during 1969-77 and remeasured as adults in 1988-89 (men and women) and 1991-94 (women only). Childhood stunting was associated with a lower body mass index (BMI) and percent body fat in men, while no association was found in women. Both male and female severely stunted children had significantly greater adult abdominal fatness, after controlling for overall fatness and confounders. The adult waist:hip ratio was increased by 0.65 in men and 0.29 in women for each height-for-age z score less at age 3. Migration to urban centers was significantly associated with a greater waist:hip ratio in severely stunted females. In a subsample of 137 women, short and thin newborns had significantly greater adult abdominal fatness compared with long and thin or short and fat newborns or children who became stunted postnatally. The adult waist/hip ratio was increased by 1.58 for each kilogram less birth weight. Findings suggest that in countries where maternal and child malnutrition exist in the context of rapid economic development and urban migration, abdominal obesity and related chronic diseases are likely to increase.

[Prescriptions, access, and expenses on drugs among users of health services in Mexico]. / Prescripción, acceso y gasto en medicamentos entre usuarios de servicios de salud en México.

OBJECTIVE: To analyze the medical prescription, drug access and drug expenditure by patients based on the National Health Survey in Mexico, 1994. MATERIAL AND METHODS: A descriptive analysis of drug access and expenditure was undertaken and predictive factors for medical prescription were identified by logistic regression for 3,324 patients. RESULTS: 78% of the patients received drug prescriptions. 92% of the Social Security patients and 35% of the Ministry of Health patients received drugs free of charge (p = 0.000). The region with the highest poverty index received the least amount of drugs free of charge. Regarding drug expenditure of patients who purchased drugs, median expenditure was 40.00 pesos (12.50 USD). Private health service patients spent significantly more than public health service patients. CONCLUSIONS: Drug access and drug expenditure are linked to socioeconomic factors and to the institutions attended by patients. The Mexican health system faces, among others, the challenge of increasing the equity of access to medical drugs.

[Utilization of health services by febrile patients in a malaria transmission area in Mexico]. / Utilización de servicios de salud por febriles en un área de transmisión de paludismo en México.

OBJECTIVE: To analyze primary health care service (PHCS) utilization by febrile patients in a malarial area of Mexico. MATERIAL AND METHODS: A cross-sectional study was carried out in September, 1993, in 32 communities of Tabasco (decentralized health services) and Campeche (non-decentralized) states. Predictors of utilization were analyzed using descriptive statistics and logistic regression analysis. RESULTS: 817 febrile patients received care at home 55% of all febrile patients received care at home (SELF), 16.5% by PHCS and 17% by volunteer collaborators, with no significant differences in health services utilization between states. Febrile patients living in communities where PHCS was available used these facilities 11 times more than those without PHCS (C.I. 95%: 7.0-18.2%). Severely febrile patients used PHCS 2.8 times more than mild-moderate cases (C.I. 95%: 1.7-4.6%). Febrile patients under 13 years of age used PHCS 1.9 times more than older patients. Two per cent of febrile patients consisted of malaria cases. CONCLUSIONS: There was no difference between decentralized and non-decentralized health services regarding the utilization of PHCS. Fever symptoms must be evaluated as a single screening indicator of malarial disease.

Optimal timing of granulocyte colony-stimulating factor (G-CSF) administration after bone marrow transplantation. A prospective randomized study.

The positive role of G-CSF in hastening the myeloid recovery of patients undergoing allogeneic bone marrow transplantation (ALLO-BMT) or autologous bone marrow transplantation (ABMT) has recently been established. Considerable knowledge about adequate doses and route of administration has been accumulated in the past few years. Nonetheless, the optimal time to start growth-factor administration remains undetermined. We have performed a stratified study according to the source of hematopoietic progenitors (ALLO-BMT or ABMT), underlying disease and its stage, and acute graft-versus-host disease (GVHD) prophylaxis regimen and randomized patients in two arms: group A, which started G-CSF on day 0 (36 patients), and group B, which started on day +7 post-BMT (39 patients). The same dose (5 micrograms/kg/day) and route of administration were employed in both groups. We found no significant differences in the time to reach an absolute neutrophil count (ANC) of 0.1, 0.5, and 1 x 10(9)/l and 50 x 10(9) platelets/l (medians: 10 and 11, 14.5 and 14, 17 and 16, 23 and 24 days, respectively, in groups A and B). We did not find differences in the days of fever or days on antibiotic treatment with less than 1 x 10(9)/l ANC, rate of bacteriemia, or days of hospitalization in both groups. In contrast, a considerable saving of G-CSF in B group was found (mean days of infusion in group A, 18, versus 11 in group B) (p < 0.0001). This is equivalent to a saving of 1120 $US per patient.(ABSTRACT TRUNCATED AT 250 WORDS)

[International migrations: the uncertain future of the world population]. / Las migraciones internacionales: futuro incierto de la populacion mundial.

PIP: "Migration is a worldwide phenomenon that responds basically to the necessities of the international labor market and to other factors of socio-political and economic nature.... In ancient times...humanity registered considerable migratory flows, whether because of war, hunger, religion, illness or other factors. The demographic projections for underdeveloped countries indicate that their population will increase for the next century due mainly [to] two reasons: the mortality rate has been reduced in those countries thanks to technological development of the medical services; and [increasing birth rates]." (EXCERPT)^ieng

[Preferences on family composition among youngsters from Monterrey, Mexico]. / Preferencias sobre la composición familiar entre jóvenes de Monterrey, México.

In order to evaluate the effect of social and biological factors on family size (FS) and secondary sex ratio (SSR) in the families that they would desire to procreate as well as in the ones to which they belong, 1,518 unmarried persons of both sexes, students and workers, who reside in the metropolitan area of Monterrey, Mexico were interviewed. It was found that the average FS desired by the unmarried males and females, independently of their socioeconomic level and years of schooling, were 3.19 and 3.04, which are lower than half the FS of 6.81 observed in the families to which they belong. Both males and females in all the socioeconomic levels and years of schooling, would desire to procreate a larger number of male children: SSR of 0.576 and 0.524, which are higher than the 0.498 observed in the families to which they belong. Also they manifested a strong preference for the birth order of the sex of their children, being of males for the first (SSR of 0.924 and 0.838) and of females for the second (SSR of 0.301 and 0.269). The fact that all children would be of the same sex did not change the desired FS in about 80% of the persons, but in the remainder 20% the desired FS would be increased to an average of five children. In order to reduce the growth rate it would be convenient to offer special counseling on family planning to these persons. In conclusion, the obtained information indicates that aside from the socioeconomic, cultural and biological factors, probably the family planning programs have had a positive influence on the persons that in the near future will start their reproductive stage, and it is possible to anticipate a reduction on the growth rate for the next generation.

[Surgical sterilization: 10 years' experience]. / Esterilización quirúrgica: experiencia en 10 años.

PIP: A sample of 1003 records of surgical sterilizations was studied from among the 9400 performed between July 1972-June 1982 at a university hospital in Nuevo Leon, Mexico. 12 patients were aged 15-19, 104 were 20-24, 244 were 25-29, 291 were 30-34, 267 were 35-39, and 85 were 40-45. Not all patients met the recommended conditions of being at least 25 years old and/or having at least 3 pregnancies. 11.6% of the patients were sterilized because of psychiatric problems, multiparity, 2 previous cesarean sections or on request of the spouse. 95.5% of the women were married, 2.1% were single, 1.6% lived in free union and .8% were widowed. 14.0% were illiterate, 57.7% had incomplete primary educations, 19.3% had completed primary school, 2.5% had incomplete secondary or technical schooling, and .3% had professional studies. 27 women had had 0-2 pregnancies, 336 had 3-5, 336 had 6-8, 198 had 9-11, and 106 had 12 or more. The maximum number of pregnancies was 20 and the average was 7.1/woman. 6 women had preoperative hemoglobin levels of 6.0 g or less, 12 had 7.0 g, 44 had 8.0, 119 had 9.0 g, 756 had 10.0, and 566 had 11.0 g or higher. Transfusions were given to all women with less than the minimum level of 10.0 g. 460 of the operations were postpartum, 334 were transcesarean, and 209 were interval procedures. 696 operations were done by the Pomeroy method, 52 by modified Pomeroy, 27 by fimbriectomy, 16 by salpingectomy, and 2 by the Uchida method. Among laparoscopic methods, 82 were done by cauterization and 128 with Yoon rings. 392 postpartum and 286 transcesarean operations were performed using the Pomeroy technique, while 82 interval sterilizations were done using cauterization and 107 using Yoon rings. Epidural anesthesia was used in 457 postpartum and 325 transcesarean procedures, while general anesthesia was used in 175 interval sterilization. There were few transoperative complications. There were 2 cases of failure to achieve salpingoclasy, 4 cases of hemorrhage, 1 case of burning of the visceral wall, 1 case of anesthetic accident, and 12 cases of other complications. Among postoperative complications there were 15 cases of abdominal pain, 1 each of fever and infection, and 1 of other complication. There was 1 pregnancy among the 1003 cases. All the procedures were performed by physicians in training.^ieng

[Psychobiology of human fertility in Mexico. I. Educational aspects of the universitary campaign on family planning]. / Estudios psicobiológicos de la fertilidad humana en México. I. Aspectos educativos de la campaña universitaria de planificación familiar

PIP: In view of the scarce information about family planning among the Mexican population, audiovisual material was prepared to promote the mehtods and benefits of family planning. The material consists of 22 slides, recorded explanation, and music. Psychological factors, such as sensory perception, image symbiolism, language, education, sex, attention span, motivation, and identification, and social factors, such as status and recognition, were taken into consideration. The program is presently shown to an average of 120 persons daily, including outpatients and hospital patients. Its use led to a considerable increase in the number of patients who voluntarily attend the family planning clinic for medical advice on fertility control.^ieng